Download Incidence of GDV Gastric Dilatation-Volvulus Risk Factors What Can

GASTIC DILATATION-VOLVULUS
Incidence of GDV
GASTRIC DILTATION VOLVULUS:
FROM TRIAGE TO DISCHARGE
Elisa M. Mazzaferro, MS, DVM, PhD, DACVECC
Oliver D.E. Morgan VMD, DACVS
Cornell University Veterinary Specialists
October 4, 2015
from speedyvet.com
Gastric Dilatation-Volvulus
 First
reported in 1906 in dogs
 Also known as:
–Bloat
–Gastric torsion
–Torsion
–Gastric dilatation
–GDV
What Can We Do?
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Risk Factors
Large or giant breed dogs
Pure bred dog (8.6 to 1)
Advancing age
Hepatosplenic ligament
length
Physical conformation
Temperament
Reduced thoracic
width:depth ratio
Height
Splenectomy
Gastric foreign body
Other Implicating Factors
 Gastrin
 Myoelectric
dysfunction
LES sphincter pressure
 Delayed gastric emptying
 Aerophagia
 Esophageal motility disorders
 Feeding practices
 Increased
GASTIC DILATATION-VOLVULUS
Can We Change The Food?
Feeding Practices?
 Smaller
 Feeding
food particles increases risk?
oil or fat listed as
one single food alone?
multiple smaller meals may decrease
 Dry food that contains
1st 4 ingredients
 Feed
 Feeding
one single food alone?
 Feed multiple smaller meals may decrease
risk
 Feeding dry with fish or eggs may
decrease risk
 Raising
Environmental Factors
Can We Prevent?
 Recent
risk
the food bowl?
– Actually increased risk of GDV
kenneling or car ride
 Stress/agitation
 Increased
 More
atmospheric pressure
than 50% November to January (TX)
Presenting Complaints
Physical Examination
 Retching
 Pale
or unproductive vomiting
 Lethargy
 Swollen
or distended abdomen
 Restlessness
 Pytalism
 Straining
to defecate
or moaning
 Recumbancy
 Grunting
mucous membranes
breathing
 Retching
 Distended tympanic abdomen
 Tachyardia with bounding or weak
pulses
 Irregular heart rhythm
 Labored
GASTIC DILATATION-VOLVULUS
Treatment Guidelines
Consequences of GDV
 Gastric
 Hemodynamic
decompression
 Restore preload
 Improve organ perfusion
 Decrease lactic acidosis
 Treat dysrhythmias
Effects
–Decreased venous return
–Decreased cardiac preload
–Decreased cardiac output
–Hypotension
RESTORE
PERFUSION
Consequences of Decreased Cardiac
Output
 Hypotension
 Inadequate
diastolic filling
 Coronary artery hypoperfusion
 Myocardial hypoxemia and acidosis
 Arrhythmias
 Further decline of cardiac output
Cardiac Output
Dysrhythmias
Q = Heart Rate x Stroke Volume
Tachycardia
Bradycardia
Afterload
Preload
Decreased venous return
Intravenous Catheter
Contractility
Inflammatory cytokines
Myocardial depressant factor
Lactic acidosis
Fluid Therapy
 90
ml/kg/hour IV
with ¼ of calculated
volume
 Constant reassessment of
perfusion parameters
 Start
 Heart rate
 Blood pressure
 Mucous membrane color
and CRT
GASTIC DILATATION-VOLVULUS
Colloids
What About the Bloat Bucket?!?!
Two buckets
Orogastric tube(s)
Pump
5 – 10 ml/kg bolus
Passing the Orogastric Tube
Passing the Orogastric Tube
Mark the tube
Secure roll of two
inch tape in mouth
and around muzzle
Measure from tip of mouth to last rib
Passing the Orogastric Tube
Gastric Lavage
Lubricate tip of tube and pass through the
middle of the tape roll
Look for necrotic mucosa
GASTIC DILATATION-VOLVULUS
Ausculting the Abdomen
Percuss and listen for
most tympanic area
Trocharization
Tent skin and slowly introduce
large bore over-the-needle catheter
The Electrocardiogram
Sinus Tachycardia
Trocharization
Clip and scrub over most tympanic area
Trocharization
Advance needle off of catheter
and allow air and fluid to
flow…. Stand back!
The Electrocardiogram
Ventricular Premature Contractions
(VPC’s)
GASTIC DILATATION-VOLVULUS
Electrocardiogram
Electrocardiogram
isoelectric shelf
Multiform VPC’s
R on T
no isoelectric shelf
Cardiac Dysrhythmias
Treatment of Dysrhythmias
 Indications
 Lidocaine
for treating ventricular
dysrhythmias
–Prolonged ventricular tachycardia >
160/min
–Multiform ventricular tachycardia
–“R on T” or ventricular flutter
–Anesthesia
Arterial Blood Pressure
–1 – 3 mg/kg IV
–IV CRI 50 – 100 mcg/kg/min
 Crystalloid bolus
–5 – 10 ml/kg
 Supplemental oxygen
Analgesia
(0.005 – 0.02 mg/kg IM
or IV)
 Fentanyl 2 mcg/kg IV bolus
 Avoid morphine and hydromorphone
due to potent emetic effects
 Buprenorphine
GASTIC DILATATION-VOLVULUS
Diagnostics
 Minimum
Venous Lactate
data base
 PT/APTT
 Venous
lactate
 Electrolytes
 Blood
pressure
 ECG
 Radiographs
> 6.0, 7.4 mmol/L increases risk of mortality
Venous Lactate
Venous Lactate
Decrease to 50% of baseline
Radiographs
Right lateral abdomen
GASTIC DILATATION-VOLVULUS
Unusual GDV
Food Bloat
LOOK FOR PNEUMATOSIS
Prognosis with Gastric Necrosis
Thoracic Radiographs
GASTIC DILATATION-VOLVULUS
Balanced Anesthesia
Anesthesia
 Reasons
for administering
premedication
–Decrease anxiety
–Provide analgesia
–Decrease total induction and
maintenance anesthetic doses
• Attempt to minimize
cardiovascular depression
 Opioid
Anesthetic Agents to Avoid
 Phenothiazine
Fentanyl
5-10 mcg/kg IV
Midazolam
Diazepam
0.2-0.5 mg/kg IV
0.4 mg/kg IV
Etomidate
0.5 – 1.0 mg/kg IV
Maintaining Blood Pressure
 Avoid
fluid loss
 Crystalloid and colloid boluses
 Use of inotropic agents
 Use balanced anesthesia
 Use of pressor agents
tranquilizers
 α-blockage causes peripheral vasodilation
 Alpha-2
+ Benzodiazepene ± Etomidate
Agonists
 Decreased CO and hypotension
 Propofol
 Vasodilation
 Ketamine
 Direct myocardial depression in most critical
patients
Decrease Anesthetic Depth
CRI Fentanyl
Fluids
Inotropes
Dopamine
Mechanical ventilation
Blood
Circulating Volume
Ephedrine
Oxyhemoglobin
BLOOD PRESSURE
Fluid Balance
Crystalloids
Colloids
Blood
Oxyhemoglobin
Anesthetic Monitoring
Dobutamine
Control Dysrhythmias
Lidocaine
Pressors
Epinephrine
Norepinephrine
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Electrocardiogram
Blood Pressure
Pulse oximetry
End-tidal CO2
GASTIC DILATATION-VOLVULUS
Surgery
As soon as patient is stabilized as best as
possible
– Patient may still be very unstable
▪ Plan:
▪
Gastric Dilatation Volvulus
From Triage to Discharge
– Correct gastric malpositioning
– Assess/treat gastric and splenic
ischemic injury
– Deal with and stop hemorrhage
Oliver D. E. Morgan, VMD, DACVS
Cornell University Veterinary Specialists
October 4, 2015
• Typically from short gastric arteries
– Prevent recurrence with a gastropexy
Surgery: Exploratory
Ventral midline laparotomy
▪ If twisted, stomach is found as soon as
you enter the abdomen covered by the
greater omentum ventrally
▪ Intra-op needle gastrocentesis will
facilitate visualization and repositioning
– Perform prior to placing Balfour and
prior to attempting to pass orogastric
tube
– Once signicantly decompressed then
pass orogastric tube
▪ Hemoabdomen
▪
– rupture of the short gastric arteries
Surgery: Gastric derotation
▪
Usually 180 degree and
clockwise twist:
– Grasp pylorus with one hand on
the left side of the body and
stomach on the right side with
other hand
– Push down on the right and pull
pylorus up
– Gently untwist stomach by
moving it from a left to ventral to
right direction
– Aided significantly by completely
decompressing first
Surgery: Gastric viability
Gastric necrosis most common along the
greater curvature at the fundus
▪ Evaluation
– red
– purple
– gray-green
– black
– thinning
– torn
▪
GASTIC DILATATION-VOLVULUS
Ugh……
Surgery: Gastric resection
Gastric compromise near the cardia is
technically demanding to resect
– Placement of an orogastric tube can help
plan stomach resection
▪ Resect full thickness stomach wall until
bleeding tissue is encountered
▪ Closure is done in two layers
– mucosa and submucosa
– muscularis and serosa
▪
Surgery: Partial
gastrectomy
Surgery: Partial gastrectomy
• Pre-place stay sutures
• Cut and inspect edges for
bleeding
• Absorbable monofilament
suture
• Simple continuous first layer
• Simple interrupted or
continuous inverting pattern
second layer
• Do not invaginate the
necrotic or devitalized
stomach
• Place gastric tube to
decompress stomach
postsurgically
Surgery: Splenic viability
▪
Other techniques
–Surgical staples
• GIA-50
• TA-90
• staple line should overlap and be oversewn
–Invagination – not recommended
• invert and sew over necrotic tissue by apposing healthy
serosa
• necrotic portion of stomach will be digested and can
create ulcer and bleeding
Surgery: Splenectomy
▪
After gastric derotation, evaluate spleen in its
normal position
▪ Examine splenic vessels for arterial
thrombosis and absence of pulses
▪
• If twisted, do not
untwist prior to
removal
• If questionable,
perform splenectomy
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▪
Surgical staples
ligature techniques
Vessel sealing devices dramatically decrease
surgical time
– Can cauterize, coagulate, and divide vessels
up to 7mm
GASTIC DILATATION-VOLVULUS
Surgery: Gastropexy
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▪
Commonly used techniques
– Incisional
– Tube gastropexy
– Circumcostal
– Belt-loop
– Incorporating – DO NOT PERFORM
Other reported techniques
– Fundic gastropexy
– Gastrocolopexy—recurrence rate higher than with other
techniques (20% vs 4% for circumcostal)
– Percutaneous Gastrostomy—weak, not recommended
Incisional Gastropexy
Incisional Gastropexy
Simple and fast
A 4-5 cm seromuscular incision is made in
the pyloric antrum
▪ Matching incision made through
peritoneum and transverse abdominus
muscle 3cm caudal to 13th rib
▪ Suture edges craniodorsally dorsal to
ventral, then caudoventrally dorsal to
ventral and tie to one another
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▪
GASTIC DILATATION-VOLVULUS
Tube Gastropexy
• Easy to perform
• Provides enteral
access
• Provides means for
decompression postop
Tube Gastropexy
• 20 Fr. Tube for big
dogs
• Mila tube is great tube
and helps prevent
dislodgement
• Surgically tacked to
body wall in box
pattern
Belt-Loop Gastropexy
Seromuscular flap made in pyloric
antrum which has a central branch of
the right gastroepiplic artery at its base
▪ A belt-loop of transversus abdominus
muscle is created 3-4cm caudally to
the costal arch and ~1/3 of the distance
from the ventral to dorsal midline. Two
parallel incisions (~2.5cm long and
2.5cm apart) are made through parietal
peritoneum and transversus
abdominus fascia
▪
Circumcostal Gastropexy
▪
Flap of serosa/muscularis created on stomach
▪
Passed around the 13th rib
▪
Sutured back to stomach
▪
Strong
▪
Annoying to perform
▪
Unnecessary security
What Should I Anticipate
Post-Op?
 Ventricular
dysrhythmias
 Gastrointestinal hypomotility
 Electrolyte imbalances
–Hypokalemia
 Systemic Inflammatory Response
(SIRS)
 DIC
Post-op Complications
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Aspiration pneumonia
Gastritis
Peritonitis/Sepsis
Reperfusion Injury
Disseminated Intravascular Coagulation (DIC)
Thromboembolic disease (PTE)
Systemic Inflammatory Response Syndrome
(SIRS)
Multiple Organ Dysfunction Syndrome (MODS)
Acute Lung Injury (ALI)
Acute Respiratory Distress Syndrome (ARDS)
GASTIC DILATATION-VOLVULUS
Postoperative Management
Postoperative Management
Most important part of management of
GDV
▪ Patients should be monitored 24 hours a
day following GDV surgery
▪ Vital signs
– Heart rate, rhythm, pulse quality
– Mucous membrane color, perfusion
– Urine output
– Body temperature
– Weight
▪
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▪
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Analgesia
– Opioids – fentanyl cri,
buprenorphine
Gastric protectants
– H2 blockers
– Acid pump inhibitors
Feeding
– Start after 24-48 hours
– Consider gastric motility
enhancers
• Metoclopramide 1-2 mg/kg/day
▪
▪
Nursing care
24 hour monitoring for 1-2
days
Post-Op Treatment and
Monitoring
Post-Op Treatment and
Monitoring
 Fluid
 Ventricular
Balance
–2.2 ml/kg/hour
–+/- 20 – 30 ml/kg/day
colloid support
– +/- urine output
–+/- Measure and
record volume of
emesis or nasogastric
suctioning
Post-Op Treatment and
Monitoring
 Ventricular
Dysrhythmias
–Procainamide
• 10 – 15 mg/kg IV, then 25 – 50
mcg/kg/min CRI
• 10 – 20 mg/kg PO QID
WATCH POTASSIUM AND MAGNESIUM!
Dysrhythmias
–Lidocaine CRI 30 mcg/kg/min,
increase dose to 100 mcg/kg/min as
necessary
–Treat if V-tach > 160 bpm, R on T, or
multiform
Post-Op Treatment and
Monitoring
• Hypomotility
• Myoelectric activity
impaired for 48-72h
post-op
– Metoclopramide CRI
• 1 – 2 mg/kg/day IV
CRI
– Use lowest dose of
opioid necessary to
maintain adequate
analgesia
– Lidocaine
– Gastric suctioning
GASTIC DILATATION-VOLVULUS
Analgesia Post-Op
– Adequate analgesia is paramount
– Fentanyl CRI
• 2 – 7 mcg/kg/hour
– Lidocaine CRI (analgesia and rhythm control)
• 15 – 30 mcg/kg/min
– Morphine CRI
• 0.1 mg/kg/hour or 0.2 – 0.5 mg/kg IM or SQ
– Buprenorphine
• 0.01-0.015 mg/kg IV or IM
Post-Op Treatment and
Monitoring
 Systemic
Inflammatory Response
Syndrome (SIRS)
 Temperature < 100°F or > 103.5°F
 Respiratory Rate > 20 breaths/min
 PaCO2 < 32 mm Hg
 Heart rate > 160 bpm
 WBC < 4,000 or > 12,000, > 10%
bands
Post-Op Treatment and
Monitoring
Post-Op Treatment and
Monitoring
 Disseminated
 Nasogastric
Intravascular Coagulation
–Daily platelet counts and
coagulation tests
• APTT/PT
• FDP’s or D-dimers
• Antithrombin levels
Prognosis
▪
Overall mortality rate is 15-30%
–Required for refractory hypomotility
–Can develop hypochloremic
metabolic alkalosis
–Keep track of amount lost so you
can replace!
Prognosis
▪
– Without gastric necrosis-2%
– With gastric necrosis-34-46%
▪
Gastric necrosis and surgery where partial
gastrectomy with or without splenectomy are
performed have mortality rates of 55% and
32%
▪
Cardiac arrhythmias occur in ~ 40% of dogs
with GDV (may or may not be associated with
outcome)
suctioning
▪
▪
Preoperative plasma lactate concentrations > 6
mmol/L are predictive of gastric necrosis and thus
a more guarded prognosis
– Lactate < 6 mmol/L 99% survival
– Lactate > 6 mmol/L 56% survival
– Lactate >7.4 mmol/L 82% accurate predictor of
gastric necrosis
– Lactate >7.4 mmol/L 88% accurate predictor of
outcome
Gastropexy is effective at preventing recurrence
– recurrence rate with gastropexy: 4%
– recurrence rate without gastropexy: 42-72%
Overall survival ~85%
GASTIC DILATATION-VOLVULUS
Recommendations to Owners
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Do not breed dogs with first-degree relatives that have
history of bloat or GDV
Feed several small meals a day, do not raise food bowl
Avoid stress and activity around meal time?
Educate owners on the clinical signs of GDV
Strongly consider prophylactic gastropexy in high-risk
dogs
– Laparoscopic or laparoscopic-assisted minimizes
morbidity
– Gastropexy at time of spay
• Practice building
Strongly recommend for Great Dane, German Shepherds,
giant breeds, deep chested breeds
Laparoscopic-assisted
Gastropexy
• Minimally invasive
• Can be performed in
conjunction with
spay or neuter
• Minimize morbidity
• Fast recovery
• Decreased infection
rates
• Small incisions
Take Home Points
Emergency stabilization and postoperative care/monitoring are the keys to a
successful outcome.
▪ Permanent gastropexy should always be
performed in conjunction with exploratory
laparotomy of GDV patients.
▪ Veterinarians should be comfortable with
the surgical techniques of gastric
resection, splenectomy and gastropexy if
managing GDV.
▪
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